CurrentAnthemPolicy N/A

Crowns, Inlays, and Onlays

Defines clinical criteria, documentation, and coding guidance for coverage determinations of indirect restorations (crowns, inlays, onlays) for Anthem dental plans; affects providers submitting claims and requests for benefit determination.

Policy Summary

PayerAnthem

PolicyCrowns, Inlays, and Onlays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionInclude current (within 1 year), dated, and properly identified pretreatment radiographic images and required documentation when requesting benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

31+sample procedure codes included

1 yrradiograph recency

6‑pointperiodontal documentation

08/23/2023last review

Coverage Criteria for Indirect Restorations

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Primary indications: 1) An anterior tooth must demonstrate significant loss of coronal tooth structure due to caries, fracture, or defective restoration and/or involvement of one or both incisal angles or cusp tip (canines); 2) A posterior tooth must demonstrate significant missing tooth structure due to caries, fracture, or defective restoration and/or large restorations that compromise function or undermined cusps (one or more cusps); 3) Fractured teeth due to external trauma should first be referred to the member's medical plan; fractures must involve missing tooth structure extending into dentin; 4) Teeth with developmental grooves or craze lines confined to enamel do not qualify;group contract dependent in parts

See documentation and periodontal/endodontic requirements below.

Periodontal and endodontic considerations: 5) Periodontal health must be addressed: uncontrolled or untreated periodontal disease (radiographic or charting evidence, bone loss, furcation involvement) may preclude coverage unless definitive periodontal therapy and maintenance have been performed or included in a treatment plan; current dated 6‑point periodontal charting and history of periodontal therapy may be requested; 6) Endodontic status must be acceptable: placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered; placement on a tooth with an unresolved carious lesion in close proximity to the pulp without planned endodontic therapy will not be considered; endodontic obturation ideally extends 0.5–1.2 mm from the apical constriction with appropriate fill density.

See Dental Policy 03-001 Endodontic Therapy.

Structural and service limits: 7) A tooth must exhibit significant structural loss from decay, fracture, or trauma to warrant an indirect restoration; 8) Temporary/provisional crowns are considered part of the final restoration and are not eligible for separate benefit; 9) Replacement for metal allergy requires physician documentation; 10) Age, occlusal function (including for third molars occlusion of at least 1/3 of an opposing tooth), and crown-to-root ratio may affect benefit determinations and are group contract dependent.

See chunks 6 and 8 for service limits and exceptions.

Exclusions and cosmetic limitations: 11) Indirect restorations placed for repair of attrition, abrasion, erosion, or abfraction are not covered by most group contracts; 12) Crowns placed solely for cosmetic reasons (discoloration, misshapenness), for occlusal alterations, changes in vertical dimension, or treatment of TMJ/craniomandibular disorders do not meet criteria for benefits; 13) Indirect restorations placed solely as survey crowns or to act as a plane for a removable partial denture are not covered; 14) Benefits will not be considered when subgingival/subosseous caries may compromise supracrestal tissue attachment or when caries extends into the furcation unless restorative and periodontal issues are addressed.

Group contract dependent in some exclusions.

Cracked tooth syndrome

Covered for cracked tooth syndrome when ALL of the following are documented:

Cracked tooth diagnosis support: a) Chart documentation of the patient’s oral complaints and current symptoms including onset, frequency, and duration; b) Symptoms reproducible on biting or pressure, verified by clinical evaluation (pain on biting or release of biting); c) Oral evaluation including contributing factors; d) A documented diagnosis of cracked tooth syndrome; e) Endodontic evaluation demonstrating no irreversible pulpal involvement requiring endodontic therapy; f) Structural integrity sufficient to restore the tooth to function; g) Radiographic images demonstrating no vertical or horizontal root fracture below the soft tissue attachment level;

All items must be present and documented in chart notes/patient records; additional information may be requested.

Primary tooth in adult dentition

Covered for a primary tooth within an adult dentition when ALL the following are met:

Primary tooth criteria: Radiographic images must demonstrate an intact root structure, adequate periodontal support with no evidence of active periodontal disease, and occlusal function with an opposing tooth; radiographs must show no permanent tooth successor present or that the permanent successor is unlikely to erupt; when these conditions are met the primary tooth may be considered for full coverage indirect restoration placement.

Documentation must be provided via radiographic imaging as described.

Coding Guidance and Sample Codes

Sample CDT Inlay/Onlay codesCDT

D2510	Inlay — metallic one surface
D2520	Inlay — metallic two surface
D2530	Inlay — metallic three or more surfaces
D2542	Onlay
D2543	Onlay — metallic three surface
D2544	Onlay — metallic four or more surfaces
D2610	Inlay — porcelain/ceramic one surface
D2620	Inlay — porcelain/ceramic two surfaces
D2630	Inlay — porcelain/ceramic three surfaces
D2642	Onlay — porcelain/ceramic two surfaces

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1/2

Sample CDT Crown/Prefabricated codesCDT

D2662	Onlay — resin-based composite two surface
D2663	Onlay — resin-based composite three surface
D2664	Onlay — resin-based composite four or more surfaces
D2710	Crown — resin-based composite (indirect)
D2712	Crown — resin based composite (indirect)
D2720	Crown — resin with high noble metal
D2721	Crown — resin with predominantly base metal
D2722	Crown — resin with noble metal
D2740	Crown — porcelain/ceramic substrate
D2750	Crown — porcelain fused to high noble metal

1–10 of 29

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Endodontic obturation ideal fill distance

Endodontic obturation — ideal fill distanceRoot canal filling should extend as close as possible to the apical constriction (ideal 0.5-1.2 mm) with appropriate fill density.

Clinical implicationOverextension or significant underfill beyond recommended range may affect benefit determination and relate to policy 03-001 Endodontic Therapy.

Documentation to includeRadiographic evidence of obturation length and density on pretreatment images (current, dated, and identified) may be requested.

Occlusion requirement for third molar crowns

Third molar crown occlusion requirementCompleted crown must be in occlusal function with an opposing tooth and must occlude with at least 1/3 of an opposing tooth.

ExceptionsExceptions may be considered for crowns supporting removable or fixed partial dentures (group contract dependent).

Benefit considerationLack of sufficient occlusion may result in the crown not meeting coverage criteria.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization / Documentation Requirements

Prior authorization may be required per contract. When requesting a benefit determination for an indirect restoration, include all required documentation and radiographs to support medical/dental necessity.

Include current (within 1 year), dated, and properly identified pretreatment radiographic image(s) that show the radiographic apex.
Attach clinical chart notes and intra-oral photographs when the radiograph alone does not clearly document the need for an indirect restoration.
Be aware that benefits are contract dependent; the plan may require proof that the service meets generally accepted standards of dental care at the lowest cost that properly addresses the patient’s condition.

Note

Expectation to Consider Less Expensive Restorations

The plan expects clinicians to consider less expensive restorations (for example, direct resin-based composite or amalgam restorations) when they can reasonably restore tooth form and function. An indirect restoration should be selected only when a less costly, clinically appropriate alternative cannot achieve adequate long-term function or structural integrity.

Alternatives such as direct restorations should be documented in the chart notes when an indirect restoration is requested.
Group contract language may allow alternation to a composite or amalgam restoration; verify contract-specific coverage rules.

Documentation Required

Radiograph and Diagnostic Documentation

Must include current (within 1 year), dated, and properly identified pretreatment diagnostic radiographic image(s) that include the radiographic apex. Additional required documentation may include clinical chart notes, intra-oral photographs, and current dated 6‑point periodontal charting when applicable.

Radiographs must be dated and clearly identify the patient and tooth/teeth in question.
If radiographic findings do not clearly justify the indirect restoration, submit intraoral photographs and clinical notes explaining the rationale.
Periodontal documentation (6‑point charting, history of periodontal therapy) is required when periodontal status may affect restoration prognosis.

Denial Risk

Denial Risk — Untreated Periapical/Periradicular Pathology

Placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered for benefit.

If periapical or periradicular pathology is present, endodontic therapy must be completed and documented prior to consideration of an indirect restoration benefit.

Denial Risk

Denial Risk — Unresolved Caries Near the Pulp

Placement of an indirect restoration on a tooth with an unresolved carious lesion in close proximity to the pulp chamber, without planned endodontic therapy, will not be considered for benefit.

If caries approaches the pulp and endodontic therapy is indicated, treatment planning and documentation must include the planned endodontic therapy prior to approval for an indirect restoration.

Definitions

Indirect restoration (definition)

DefinitionA laboratory-fabricated restoration (inlay, onlay, crown) placed when a tooth cannot be reasonably restored with direct amalgam or resin-based composite due to extensive structural compromise from decay, fracture, or defective restoration.

Typical indicationsUsed for teeth with extensive decay, large defective restorations, or traumatic fracture where direct restoration would not restore function.

Relation to coveragePlacement is reviewed for medical/dental necessity and group contract requirements; benefits depend on meeting clinical criteria and contract terms.

Delivery date for indirect restorations

Delivery date definitionConsidered the date of initial cementation or bonding of the final indirect restoration regardless of cement or bonding agent type.

Cement type irrelevanceThe use of temporary versus permanent cement does not determine the delivery date.

Contract dependenceDate of service/payment may be contract dependent (some contracts use preparation date instead).

OpenPayer

Crowns, Inlays, and Onlays

Coverage Criteria for Indirect Restorations

Coding Guidance and Sample Codes

Provider Requirements and Prior Authorization

Background

Definitions